Enrollment Application

Child Information

Child's First Name *

Child's Last Name *

Date of Birth *

Gender

Home Address *

City *

ZIP Code *

Parent/Guardian 1 (Primary Contact)

Full Name *

Relationship to Child *

Cell Phone *

Email Address *

Employer

Work Phone

Parent/Guardian 2 (Optional)

Full Name

Relationship to Child

Cell Phone

Email Address

Emergency Contacts

Please provide at least one emergency contact (other than parents) who can be reached if we cannot contact you.

Emergency Contact 1 Name *

Relationship *

Phone Number *

Emergency Contact 2 Name

Relationship

Phone Number

Authorized Pickup Persons

List all persons (other than parents/guardians) authorized to pick up your child. Valid ID will be required.

Authorized Persons (Name & Relationship)

Medical Information

Pediatrician/Doctor Name *

Doctor's Phone Number *

Allergies (Food, Environmental, or Medication)

Medical Conditions or Health Concerns

Current Medications

Special Needs, Developmental Concerns, or Accommodations

Care Schedule

Desired Start Date *

Care Type *

Days Needed (if applicable)

Monday Tuesday Wednesday Thursday Friday

How did you hear about Bridges Early Learning?

Permissions & Consents

Photo/Video Permission: I give permission for my child to be photographed or videotaped for use in Bridges Early Learning materials, including the website and social media. Sunscreen Permission: I give permission for staff to apply sunscreen to my child before outdoor activities. Field Trip Permission: I give permission for my child to participate in daily outings (zoo, parks, library, etc.) with transportation provided by Bridges Early Learning. Medical Emergency Authorization: * In case of emergency, I authorize Bridges Early Learning to seek emergency medical treatment for my child if I cannot be reached.

Additional Information

Is there anything else you'd like us to know about your child or family?

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that submitting this application does not guarantee enrollment, and I will be contacted to discuss next steps. *